Elsevier

Appetite

Volume 130, 1 November 2018, Pages 117-122
Appetite

Feeding behavior in three-year-old children born <30 weeks and term-born peers

https://doi.org/10.1016/j.appet.2018.07.030Get rights and content

Abstract

Background

Feeding difficulties threaten growth, health and neurodevelopment, and are prevalent among infants born preterm. The literature differs on (i) whether these problems persist into early childhood, and (ii) risk factors in the preterm population. In this study we explore feeding difficulties and risk factors in preterm and term-born three-year-olds.

Objectives

To determine whether three-year-olds born <30 weeks have poorer feeding outcomes than their term-born peers; and identify predictors of feeding outcomes in children born <30 weeks.

Methods

Feeding outcomes were examined in three-year-old children born <30 weeks, and a term-born comparison group, using parent report and the Behavioral Pediatric Feeding Assessment Scale (BPFAS). Factors hypothesized to be associated with feeding difficulties and preterm birth were examined in the preterm group, including: gestational age at birth, birth weight z-score, chronic lung disease (CLD), nasogastric tube (NGT) feeding at hospital discharge, age at breastfeeding cessation, oromotor feeding impairment at 12 months, weight at 12 months in kilograms and neurodevelopmental diagnoses.

Results

In 217 children (111 born <30 weeks, 106 term-born), parents of children born <30 weeks reported more feeding concerns on parent report questions than parents of term-born peers. CLD, NGT at discharge, neurodevelopmental diagnoses and weight at 12 months predicted these parent-reported outcomes. By contrast, there was no difference in BPFAS results between preterm and term groups, and BPFAS scores were predicted only by birth-weight z-score in the preterm group.

Conclusions

Behavioral feeding outcomes for three-year-old children born <30 weeks were equivalent to term-born peers in this study, however parental concerns about feeding differed. Further investigation is required to identify the drivers of parent concerns about feeding. Children displaying core risk factors warrant specific follow-up of feeding outcomes.

Introduction

Feeding difficulties in children are common and highly correlated with poorer dietary variety, weight and growth (Dubois, Farmer, Girard, & Peterson, 2006). Further, when persistent, feeding difficulties are associated with poorer neurodevelopmental outcomes (Motion, Northstone, Emond, & Team, 2001). Preterm neonates are known to be at higher risk of feeding difficulties (Jadcherla, Wang, Vijayapal, & Leuthner, 2010), but whether these feeding difficulties persist into later childhood remains a matter of debate (Crapnell et al., 2013; Jonsson, van Doorn, & van den Berg, 2013; Nieuwenhuis, Verhagen, Bos, & van Dijk, 2016; Samara, Johnson, Lamberts, Marlow, & Wolke, 2010; Sanchez, Spittle, Slattery, & Morgan, 2016). Furthermore, within the preterm population, specific risk factors of pediatric feeding difficulties remain elusive, with different studies reporting different results (Crapnell et al., 2013; Nieuwenhuis et al., 2016; Samara et al., 2010; Sanchez et al., 2017).

Very preterm-born children (born <32 weeks of gestational age) are exposed to an extensive range of potential threats to feeding development. Given the cumulative risk, the lack of consensus on whether feeding difficulties in this group persist past infancy is surprising. However, findings are divergent, with some authors reporting no evidence of increased risk of feeding difficulties among preterm-born children (e.g. Jonsson et al., 2013; Nieuwenhuis et al., 2016), and others suggesting this group are more likely to present with ongoing feeding difficulties (Crapnell et al., 2013; Samara et al., 2010; Sanchez et al., 2016). A substantive concern in the current literature is the choice of tools used to measure feeding. Due to a lack of rigorous and well-validated pediatric feeding measures (Heckathorn, Speyer, Taylor, & Cordier, 2016; Sanchez, Spittle, Allinson, & Morgan, 2015), the tools used vary in focus, detail, and psychometric properties. Existing studies commonly use purpose-designed questionnaires with limited psychometric data, or subsections of tools designed to measure other constructs. The variation in tools reflects a lack of consensus in the literature about the definition of feeding difficulties, which likely also contributes to the divergent findings (Field, Garland, & Williams, 2003). Further, the gestational age at birth of the studied population and the age at assessment vary widely. These are important considerations as gestational age at birth (e.g. late preterm vs extremely preterm) has a significant effect on other neurodevelopmental outcomes (Sansavini, Guarini, & Caselli, 2011), and feeding development tends to be rapid and variable before 36 months, and then stabilises (Arvedson, 2006). It is likely that this variance in measures and populations is responsible for the divergence in the literature.

Establishing the risk factors that may contribute to poorer feeding outcomes among children born preterm has been similarly problematic. Long periods of intubation and non-oral feeding are common in this population, and may contribute to variations in orofacial sensitivity as well as signal early oromotor feeding issues (Dodrill et al., 2004). Preterm infants are less likely to be breastfed (McDonald et al., 2013), limiting their exposure to a diverse range of tastes prior to their introduction to solid foods (Husk & Keim, 2016). They are also more likely to be fed to a schedule rather than based on their hunger cues (Watson & McGuire, 2016), potentially interrupting the development of a typical hunger-satiety cycle. Medical issues such as gastrointestinal complications (Jadcherla et al., 2010) and respiratory disease (Martin & Shaw, 1997) may affect these infants' ability to efficiently and safely feed by mouth, particularly early in life. Regulatory and attachment problems have a documented link with later feeding difficulties, and may result both from neurological abnormalities and the traumatic experience of being a hospitalised infant separated from its parents (Bilgin & Wolke, 2016, 2017). Unsurprisingly, preterm-born children also develop more neurodevelopmental problems associated with poor feeding outcomes; including altered sensory processing (Eeles et al., 2013) alongside higher rates of cerebral palsy and other neuromotor issues (Hirschberger et al., 2018).

The extant literature is limited by use of a heterogeneous group of feeding outcome measures, some of which do not have established discriminative validity for investigating feeding difficulties; and a wide variation in gestational age at birth and assessment age in the studied population. As a result, there is a need for prospective cohort research examining these questions in a large population of preterm and term-born children who are at an optimal age for feeding assessment. This will help to identify whether preterm children are indeed at greater risk of persistently poor feeding outcomes, and explore significant risk factors to identify those children who would most benefit from surveillance and assistance around their feeding development. In this paper, we aimed to determine (1) whether three-year olds born <30 weeks have poorer feeding outcomes than their term-born peers; and (2) which risk factors predict feeding outcomes in this group.

Section snippets

Participants

We recruited infants born at <30 weeks and infants born at term shortly after birth from the Royal Women's Hospital and Frances Perry House Private Hospital between January 2011 and March 2013 as part of a large cohort study of neurobehavior and neurodevelopment in term and preterm-born children (Spittle et al., 2014). Eligible families were approached by a research nurse in the first or second week of life, provided the medical team approved, and asked to complete written consent (Spittle et

Results

Participant details, including details of predictor variables, are included in Table 1 for the 217 children (106 born at term and 111 born <30 weeks) who participated in the three year follow-up stage of this study. The rate of follow-up was 72.3%. There was no difference in perinatal characteristics between the recruited sample and those children who participated in the three year follow-up.

There were no differences between preterm and term-born children for any scale on the BPFAS, but parents

Discussion

Feeding difficulties in childhood are highly concerning to parents, and are associated with negative impacts on dietary variety, growth and developmental outcomes. Some research has linked preterm birth with persistent feeding difficulties (Crapnell et al., 2013; Samara et al., 2010), but other evidence has been contradictory, suggesting that these issues resolve in early childhood (Jonsson et al., 2013; Nieuwenhuis et al., 2016). In this study, we sought to clarify this contradiction by using

Sources of support

This study was supported by the National Health and Medical Research Council (AM Career Development Award #607315; Practitioner Fellow #1105008; AS Career Development Fellowship #1108714, Centre for Research Excellence in Newborn Medicine grant #1060733; KS Centre for Research Excellence in Newborn Medicine grant #1060733), an Australian Government Research Training Program Scholarship (KS), and Speech Pathology Australia's Nadia Verrall Memorial Research Grant (KS). Murdoch Children's Research

Acknowledgments

We would like to acknowledge the VIBeS team who contributed to recruitment, data collection and analysis; Cristina Mei, Miya St. John and Jodie Smith who contributed to data collection; and the families and children who participated in this study. The authors have no conflicts of interest to declare.

KS, AS and AM designed research; KS and JB conducted research; AS provided essential materials; KS analysed data; KS, JB, AS and AM wrote the paper; KS had primary responsibility for final content.

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    Angela T. Morgan and Alicia J. Spittle are joint senior authors.

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